The information below comes from the statement of deficiencies compiled by health inspectors and provided to AHCJ by the Centers for Medicare and Medicaid Services. It does not include the steps the hospital plans to take to fix the problem, known as a plan of correction. For that information, you should contact the hospital, your state health department or CMS. Accessing the document may require you to file a Freedom of Information Request. Information on doing so is available here.


Based on observation, document review, and interview, the facility did not: (A) have a Policy for the Monitoring of Waiting Room Patients Awaiting a Medical Screening Exam (MSE), and (B) ensure in three (3) of five (5) Medical Records, that patients in the Treatment Area were not reassessed as per facility Policy and Procedure.

This potentially places patients at increased risk for unassessed changes in their medical condition.

Findings pertinent to (A) above include:

Observation in the facility's Emergency Department (ED) during a tour between 10:30AM and 1:00PM on 01/09/17 identified the following: Patient #8 was observed waiting in the Waiting Area. The patient's spouse approached the Triage Desk at 12:23PM and stated that Patient #8 had been waiting for an hour and a half (1) and was complaining of headache and now dizziness.

Review of Patient #8's Medical Record identified the following information: This [AGE]-year-old arrived to the ED on 01/09/17 at 10:56AM, after a Motor Vehicle Crash (MVC). Patient #8 was triaged at 11:19AM with a chief complaint of head, neck and back pain, eight (8) out of ten (10) in severity. Initial vital signs were documented during triage on 01/09/17 at 11:23AM. No reassessment was documented for this patient while he was in the Waiting Area.

During an interview with Staff G on 01/10/17 at 10:00AM, Staff G stated that "I personally check and eyeball the patients about every twenty (20) minutes but I don't recheck their vitals".

Per interview with Staff L on 01/11/17 at 11:20AM, Staff L stated that [staff] checks on the Waiting Room Patients every five (5) to ten (10) minutes.

This inconsistency in the reassessment of Waiting Room Patients was confirmed during interview with Staff Members B and C on 01/10/17 at 1:35PM. Staff B stated "The staff is trained to check on patients periodically but there is no specific Policy on reassessing patients in the Waiting Area". Staff C confirmed these findings.

Findings pertinent to (B) above include:

The facility's Policy and Procedure (P&P) titled "Measurement of Vital Signs [VS]" last revised 08/31/16, stated "If a patient presents with a stable primary assessment, including vital signs within normal limits, they are to be repeated every four (4) hours while the patient is waiting a disposition". This Policy refers to all patients who are assigned to a Treatment Area.

Patient #17's Medical Record identified that on 01/10/17 the patient arrived to the ED at 8:44PM after a fall, had initial triage VS performed at 8:52PM, and repeat VS performed on 01/11/17 prior to discharge at 6:31AM. Repeat VS were not performed for approximately nine (9) and a half hours (9) after the initial VS.

Patient #16's Medical Record identified that on 12/28/16 the patient arrived to the ED at 1:09AM, after running out of home oxygen at the assisted living facility, and had initial triage VS performed at 1:45AM. Repeat VS were not performed until 8:38AM, approximately six and a half hours (6) after the initial VS. Discharge VS were performed at 5:02PM, nine (9) hours after the repeat VS.

Similar findings were found in the Medical Record of Patient #14 for the review period of 11/29/16 to 11/30/16.

Per interview of Staff B and Staff M on 01/11/17 at 12:30PM, they stated that only patients with medical issues in the Treatment Areas should have VS repeated every four (4) hours as per their Policy. The current Policy does not distinguish between medical and non-medical patients.